National Imaging Associates, Inc. MYOCARDIAL PERFUSION ... Guidelines/CMS... · 4—MPI_Heart...
Transcript of National Imaging Associates, Inc. MYOCARDIAL PERFUSION ... Guidelines/CMS... · 4—MPI_Heart...
National Imaging Associates, Inc.
Clinical guidelines
MYOCARDIAL PERFUSION IMAGING
HEART (CARDIAC) PET SCAN
STRESS ECHOCARDIOGRAM
(Non-emergent outpatient testing)
Original Date: October 2015
Page 1 of 14
“FOR CMS (MEDICARE) MEMBERS
ONLY”
CPT4 Codes: Refer to pages 11 - 12 Last Revision Effective Date: November
2017
LCD ID Number: L36209
J – N = FL
Last Revised Date: November 2017
Responsible Department:
Clinical Operations
Implementation Date: December 2017
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“FOR CMS (MEDICARE) MEMBERS ONLY”
Coverage Indications, Limitations, and/or Medical Necessity
Noninvasive testing in the outpatient setting to assess coronary artery disease (CAD) and
left ventricular (LV) dysfunction may be accomplished utilizing conventional exercise
testing or by measuring the distribution of nuclear medicine reagents during physiologic or
pharmacologic stress.
Cardiovascular stress testing, also called an exercise stress test (EST), exercise
electrocardiogram, exercise treadmill test (ETT), graded exercise test, or stress
electrocardiogram (ECG), is used to provide information about how the heart responds to
exertion. It usually involves walking on a treadmill or pedaling a stationary bike at
increasing levels of difficulty, while the electrocardiogram, heart rate, and blood pressure
are monitored. The same measurement may be obtained with the substitution of
echocardiography for a standard ECG. Echocardiography is used to image cardiac
structures and function and also flow direction and velocities within cardiac chambers and
vessels. Usually these images are obtained from several positions on the chest wall and
abdomen using a hand-held transducer.
In many instances, exercise testing (without imaging) may be combined with imaging
procedures, such as myocardial perfusion imaging, radionuclide ventriculography,
echocardiography, or other imaging procedures.
There are 3 principle types of stress tests which do not involve the measurement of radio-
labelled distribution within the body. These include:
• Exercise stress test (EST) is normally the first stress test performed. The patient walks
on a treadmill or similar device while being monitored to measure endurance with an end-
point of symptoms, ECG, or echocardiographic changes that suggest coronary under-
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perfusion. EST is without imaging. An EST must include an ECG that can be interpreted
for ischemia, and the patient must be capable of exercise on a treadmill or similar device
generally at 4 METs or greater (i.e., able to walk four blocks without stopping, can climb
two flights of stairs without stopping). An abnormal EST includes any one of the following:
ST segment depression, development of chest pain, significant arrhythmia (especially
ventricular arrhythmia), or hypotension.
• Dobutamine, Dipyridamole, or Adenosine Stress Test is used in people who are unable to
exercise. A drug is given to make the heart respond as if the person were exercising. This
way the doctor can still determine how the heart responds to stress, but no exercise is
required.
• Stress echocardiogram is a graphic outline of the heart's movement. A stress echo can
accurately visualize the motion of the heart's walls and pumping action when the heart is
stressed; it may reveal a lack of blood flow that isn't always apparent on other heart tests.
The main task of Nuclear Cardiology and Nuclear Medicine is not the representation of
anatomy, as in traditional Diagnostic Radiology; rather, it is the non-invasive visualization
of functional, metabolic processes. In diagnostic Nuclear Medicine, the subject first
incorporates tracer amounts of a radioactively-labelled molecule. Once the tracer molecule
is properly distributed inside the body, imaging techniques visualize the metabolism of the
substance by measuring the distribution of the radioactively-labelled molecule through
externally emitted radiation.
Myocardial perfusion imaging (MPI) SPECT is a cardiac radionuclide imaging procedure
that evaluates blood flow to the cardiac muscle. MPI is usually performed with exercise
ECG testing for detecting coronary artery disease and determining prognosis using a
gamma camera to record images in planar or tomographic (single photon emission
computed tomography) (SPECT) projections. Use of dual radiopharmaceuticals permits
concurrent studies at rest and after stress, which is then compared and interpreted by a
nuclear physician. Since the radiopharmaceutical accumulates in the myocardium in
relation to blood flow, ischemic and infarcted myocardium can be detected. The specific
imaging technique (perfusion versus ventricular function) and the reason for the imaging
determines what radionuclide agent is employed. A perfusion study utilizes an imaging
isotope agent that reflects myocardial blood flow and, dependent on the agent and timing of
image acquisition, the presence of scar and/or ischemia. Ventricular function studies utilize
specific imaging isotopes to outline the borders of the left ventricular endocardium or to
identify the ventricular blood pool independent of the surrounding myocardium. The motion
of the left ventricle is synchronized with the electrocardiogram to generate wall motion and
ejection fraction information. In instances where an exercise test cannot be performed,
Dipyridamole, Adenosine, Dobutamine or other provocative agents may be used to alter
coronary flow, thereby unmasking a suspected lesion in the coronary bed.
Cardiac PET (positron emission tomography) myocardial perfusion imaging is another
cardiac radionuclide imaging procedure in which radioactive tracers are used to diagnose
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patients with suspected coronary artery disease (CAD) and provide important risk
stratification of patients with known CAD. This test is also a valuable tool to assess
myocardial viability, myocardial wall motion and ejection fraction, as well as, cardiac
sarcoidosis. For diagnosis, radionuclides are administered intravenously and distribute in
proportion to the regional myocardial blood flow present at the time of injection. In selected
patients, cardiac PET offers certain advantages over standard of care Single Photon
Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI). Cardiac
PET is a useful technique that allows a noninvasive evaluation of myocardial blood flow,
function, and metabolism, using physiological substrates prepared with positron-emitting
radionuclides, such as oxygen, nitrogen, fluorine, and rubidium. These radionuclides have
half-lives that are considerably shorter than those used in SPECT. Positron-emitting
radionuclides are produced either using a cyclotron, such as fluoro-2-deoxyglucose (F-18
FDG) with a 110-minute half-life, or nitrogen-13-ammonia (N-13), with a half-life of 9.8
minutes or a generator such as rubidium-82 (Rb-82) with a 75-second half-life. Because of
availability, the most common PET blood flow tracer is rubidium-82. The goal of cardiac
PET perfusion imaging is to detect physiologically significant coronary artery narrowing.
Results of the test should lead toward risk factor modification in order to delay or reverse
the progression of atherosclerosis, alleviate symptoms of ischemia, and improve patient
survival by either medical therapy or revascularization procedures such as bypass surgery
(CABG) or percutaneous coronary intervention (PCI). Stress and rest paired myocardial
perfusion studies are commonly performed to assess myocardial ischemia and/or infarction.
Current Food and Drug Administration (FDA)-approved and Centers for Medicare and
Medicaid Services-covered PET myocardial blood flow tracers are limited to Rb-82, F-18
FDG, and N-13 ammonia. Normal MPI implies the absence of significant CAD. Abnormal
myocardial perfusion on stress imaging suggests the presence of significantly narrowed
coronary arteries. If the stress regional perfusion defect is absent on the corresponding rest
images, it suggests the presence of stress-induced myocardial ischemia. If the stress
perfusion defect persists at rest, it suggests prior infarction. Imaging of myocardial
perfusion can also be combined with myocardial metabolism imaging with F-18FDG for the
assessment of myocardial viability in areas of resting hypoperfusion and dysfunctional
myocardium. The stress protocols are, for the most part, similar for all cardiac PET
perfusion agents. The specific differences in acquisition protocols for Rb-82 and N-13 are
related to the duration of uptake and clearance of these radiopharmaceuticals and their
physical half-lives.
Indications:
A cardiovascular stress test (pharmacologic and non-pharmacologic) will be considered
medically reasonable and necessary for the following conditions:
Stress Testing without Imaging: For the diagnosis of suspected and prognosis of coronary
artery disease in patients with normal or minor changes in resting ECG and no
contraindications to exercise.
Stress Testing with Imaging:
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Imaging stress tests addressed in this LCD include stress echocardiography and SPECT or
PET nuclear myocardial perfusion imaging (MPI).
Stress testing with imaging can be performed with maximal exercise or chemical stress
(dipyridamole, dobutamine, adenosine or adenosine analogs).
Stress echo and SPECT MPI are considered equivalent diagnostic tests. However, in
addition to myocardial ischemia, stress echo can provide additional information that is not
obtainable with MPI, such as valve function, assessment of pulmonary pressure, and
assessment of dynamic obstruction. The most commonly performed myocardial perfusion
imaging are single (at rest or stress, CPT code 78451) and multiple (at rest and stress, CPT
code 78452) tomographic SPECT studies. Evaluation of the individual’s left ventricular wall
motion and ejection fractions are routinely performed during SPECT MPI and are included
in the code’s definition. Attenuation correction, when performed, is included in the MPI
service.
When symptoms are present, and there is sufficient suspicion of heart disease to warrant
cardiac evaluation, it is expected that the provider make a probability estimate of the
likelihood of CAD prior to selecting testing. Assessment of coronary artery disease can be
determined by the following:
Typical angina (definite): Substernal chest pain or discomfort that is provoked by exertion
or emotional stress and relieved by rest and/or nitroglycerin.
Atypical angina (probable): Chest pain or discomfort (arm or jaw pain) that lacks one of the
characteristics of definite or typical angina.
Non-anginal chest pain: Chest pain or discomfort that meets one or none of the typical
angina characteristics.
Anginal variants or equivalents: A manifestation of myocardial ischemia, which is
perceived by patients to be (otherwise unexplained) dyspnea, unusual fatigue, more often
seen in women and may be unassociated with chest pain.
Age, gender, and the character of the chest pain provide useful predictors of CAD. Refer to
the following table for cardiac imaging guidelines.
Pre-test probability of CAD by age, gender, and symptoms:
Age
(yr)
Gender Typical/Definite
Angina Pectoris
Atypical/Probable
Angina Pectoris
Non-Anginal
Chest Pain
Asymptomatic
≤39 Men Intermediate Intermediate Low Very Low
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Women Intermediate Very Low Very Low Very Low
40-
49 Men High Intermediate Intermediate Low
Women Intermediate Low Very Low Very Low
50-
59 Men High Intermediate Intermediate Low
Women Intermediate Intermediate Low Very Low
≥60 Men High Intermediate Intermediate Low
Women High Intermediate Intermediate Low
High: Greater than 90% pre-test probability
Intermediate: Between 10% and 90% pre-test probability
Low: Between 5% and 10% pre-test probability
Very Low: Less than 5% pre-test probability
In summary, the choice of stress testing modality depends on many factors such as the
patient's ability to exercise, the resting ECG, the clinical indication for performing the test,
the patient's body habitus, and history of prior revascularization.
The following are considered medically necessary for either the stress echo or SPECT MPI:
1. New, recurrent, or worsening cardiac symptoms AND any of the following:
Physical inability to perform a maximum exercise workload
A history of CAD based on a prior anatomic evaluation of the coronary arteries OR a
history of CABG or PCI
Syncope (i.e., no prodromal symptoms, not near syncope) in patient with high
likelihood of CAD
Evidence or high suspicion of ventricular tachycardia
Age 50 years or greater and known diabetes mellitus
New or previously unrecognized uninterpretable ECG
Poorly controlled hypertension, generally, above 180 mm/Hg systolic, if the provider
feels strongly that CAD needs evaluation prior to BP being controlled
ECG is uninterpretable for ischemia due to any one of the following:
o Complete Left Bundle Branch Block (right bundle branch does not render ECG
uninterpretable for ischemia)
o Ventricular paced rhythm
o Pre-excitation pattern such as Wolff-Parkinson-White
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o > 0.5 mm ST segment depression (NOT nonspecific ST/T wave changes)
o LVH with repolarization abnormalities, also called LVH with strain (NOT
without repolarization abnormalities or by voltage criteria)
o T wave inversion in the inferior and/or lateral leads (leads II, AVF, V5, or V6)
o Patient on digitalis preparation
Worsening or continuing symptoms in a patient who had a normal or submaximal
exercise stress test and there is suspicion of a false negative result
Patients with recent equivocal or borderline testing where ischemia remains a
concern
Patients on beta blocker, calcium channel blocker, and/or antiarrhythmic medication
when the documentation supports that an adequate workload may not be attainable
to enable a fully diagnostic exercise study
History of false positive exercise stress test (e.g., one that is abnormal, but the
abnormality does not appear to be due to macrovascular CAD)
High pretest probability of CAD (assuming emergency evaluation and/or prompt
coronary angiography not previously implemented)
2. Patients without clear cardiac symptoms in the presence of an elevated cardiac troponin
3. Routine study > 3 years after a PCI (stent) without cardiac symptoms and absent an
evaluation for CAD within the past 2 years (stress echo, MPI SPECT, cardiac PET,
coronary computed tomography angiography (CCTA), cardiac catheterization)
4. Routine study > 5 years after CABG without cardiac symptoms in a patient who has not
had an evaluation for CAD within the past 2 years (stress echo, MPI SPECT, cardiac PET,
coronary computed tomography angiography (CCTA), cardiac catheterization)
5. Every 2 years in patients with documentation of previous “silent ischemia” (and diabetes
mellitus) evident on previous MPI but not evident on previous exercise stress test
6. To assess for CAD in a patient with unexplained or drug-induced intraventricular
condition disturbances
7. Prior anatomic imaging study (coronary angiogram or CCTA) to assess recently
demonstrated coronary stenosis of uncertain functional significance in a major coronary
branch can have one stress test with imaging
8. Established CAD in a patient who had an acute coronary syndrome (ACS) (ST segment
elevation MI (STEMI), Non–ST segment elevation MI (NSTEMI), unstable angina) event
within the past 90 days provided that the patient has not undergone coronary angiography
at the time of the acute event and is currently clinically stable
9. Evaluating new, recurrent, or worsening left ventricular dysfunction/CHF
10. Assessing myocardial viability in patients with significant ischemic ventricular
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dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure
such that revascularization would be considered
11. Pre-operative cardiac evaluation in patients undergoing non-cardiac surgery
o Intermediate risk surgery (cardiac risk 1-5%) one or more cardiac risk factor(s) and
inability to exercise adequately
o high risk surgery (> 5% cardiac risk)
12. Asymptomatic patients with uninterpretable ECG and no evaluation for cardiac disease
in the past 3 years
13. Planned cardiac or other solid-organ transplant if no cardiac evaluation has been
performed within the past year
14. Patients to be treated with interleukin 2 (a pro-atherogenic agent) for various
malignant disorders, etc.
15. Patients with disease conditions associated with CAD (e.g., DM, AAA, PVD, carotid
artery disease, CRF) and no documented evaluation was performed within the preceding 2
years
16. Stress echocardiography will be considered reasonable and necessary for the evaluation
of valvular heart disease and detection and management of occult pulmonary hypertension.
The following are considered medically necessary for cardiac PET:
1. For the evaluation of coronary artery disease for perfusion of the heart via myocardial
perfusion imaging, PET scans using either FDA-approved radiopharmaceutical Rubidium
82 (RB-82) or Ammonia N-13 when performed at rest or with pharmacological stress used
for noninvasive imaging of the perfusion of the heart for the diagnosis and management of
patients with known or suspected coronary artery disease, provided the following
requirements are met:
a. The PET scan, whether at rest alone or rest with stress, is performed in place of,
but not in addition to, a single photon emission computed tomography (SPECT);
OR
b. The PET scan, whether at rest alone or rest with stress, is used following a
SPECT that was found to be inconclusive. In these cases, the PET scan must have
been considered necessary in order to determine what medical or surgical
intervention is required to treat the patient. (For purposes of this requirement, an
inconclusive test is a test(s) whose results are equivocal, technically uninterpretable,
or discordant with a patient's other clinical data and must be documented in the
beneficiary's file.)
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For cardiac perfusion studies, patient selection criteria for PET scans involve an individual
assessment of the pretest probability of CAD, based both on patient symptoms and risk
factors:
Patients at low risk for CAD may be adequately evaluated with exercise
electrocardiography.
Patients at high risk for CAD will typically not benefit from non-invasive assessment of
myocardial perfusion since a negative test will not alter disease probability sufficiently
to avoid invasive angiography.
Myocardial perfusion imaging is potentially beneficial for patients at intermediate risk
of CAD (approximately 25% to 75% disease prevalence).
The risk can be estimated using the patient's age, sex, and chest pain quality. The range for
intermediate risk can vary.
The following summarizes a characterization for patient populations at intermediate risk
for CAD:
Typical Angina:
Chest pain with all of the following characteristics:
Substernal chest discomfort with characteristic quality and duration, and provoked by
exertion or emotional stress, and relieved by rest or nitroglycerin
Men ages 30-39
Women ages 30-60
Atypical Angina:
Chest pain that lacks one of the characteristics of typical angina
Men ages 30-70
Women ages 50 years and older
Non-anginal Chest Pain:
Chest pain that meets one or none of the typical angina characteristics
Men ages 50 years and older
Women ages 60 years and older
2. For the determination of myocardial viability as a primary or initial diagnostic study
prior to revascularization, or following an inconclusive SPECT. However, if a patient
receives an FDG PET study with inconclusive results, a follow up SPECT test is not
covered. The identification of patients with partial loss of heart muscle movement or
hibernating myocardium is important in selecting candidates with compromised ventricular
function to determine appropriateness for revascularization. Diagnostic tests such as FDG
PET distinguish between dysfunctional but viable myocardial tissue and scar tissue in
order to affect management decisions in patients with ischemic cardiomyopathy and left
ventricular dysfunction.
3. For the determination of cardiac involvement, using Fluorodeoxyglucose (F-18 FDG), to
diagnose cardiac sarcoidosis in patients who are unable to undergo magnetic resonance
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imaging (MRI) scanning. Examples of patients who are unable to undergo MRI include, but
are not limited to, patients with pacemakers, automatic implantable cardioverter
defibrillators (AICDs), or other metal implants.
Limitations:
The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section
5.1, outlines that "reasonable and necessary" services are "ordered and/or furnished by
qualified personnel." Services will be considered medically reasonable and necessary
only if performed by appropriately trained providers. A qualified physician for this
service/procedure is defined as follows: A) Physician is properly enrolled in Medicare. B)
Training and expertise must have been acquired within the framework of an accredited
residency and/or fellowship program in the applicable specialty/subspecialty in the
United States or must reflect equivalent education, training, and expertise endorsed by
an academic institution in the United States and/or by the applicable
specialty/subspecialty society in the United States.
The presence of risk factors for CAD, absent disease activity, is not a Medicare-covered
indication for noninvasive testing. Screening for coronary artery disease in
asymptomatic patients is not considered reasonable and necessary.
Patient selection should be based on clinical grounds. Pretest probability is based on
age, gender, symptoms, and cardiac risk factors. Selection of the test should be made
within the context of other testing modalities so that the expected information does not
become redundant. In the instance where regional wall motion abnormalities and
ejection fraction have been assessed, during the same episode of care, by other testing
modalities (i.e. echocardiography), the medical necessity of repeating this assessment
through the use of nuclear imaging modalities must be clearly documented in the
medical record. The routine and repetitive monitoring of such patients beyond the first
stress echo or MPI, in the absence of a documented clinical exacerbation (i.e., new
symptoms or progression of existing symptoms) is not considered medically necessary.
MPI SPECT/PET and stress echo are not covered in patients with low pretest
probability, interpretable ECG, and the ability to exercise.
MPI SPECT/PET and stress echo pre-operative evaluation for low risk non-cardiac
surgery is not covered.
MPI SPECT/PET and stress echo are not covered for the pre-operative evaluation of
planned intermediate risk, non-cardiac surgery, and the patient is able to exercise.
MPI SPECT/PET and stress echo are not covered for routine risk assessment for
asymptomatic patients with known CAD, who have not had a revascularization
procedure.
MPI SPECT/PET and stress echo are not covered for pre-operative, asymptomatic
patients undergoing high risk non-cardiac surgery up to 1 year following normal stress
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echo, MPI SPECT, cardiac PET, coronary computed tomography angiography (CCTA),
cardiac catheterization.
Exercise stress testing would not be expected to be performed with signs and symptoms
of cardiopulmonary instability and generally-recognized contraindications (e.g.,
unstable angina, LV dysfunction).
For patients with an abnormal resting ECG because of left bundle branch block, pre-
excitation syndrome, left ventricular hypertrophy (LVH) or digoxin therapy, an exercise
or pharmacological imaging study should be considered because the accuracy of the
exercise ECG in detecting provocable ischemia is reduced.
Cardiovascular stress testing may be performed in conjunction with additional cardiac
diagnostic tests including echocardiography and nuclear cardiac imaging. It is expected
that only the most appropriate test(s) necessary will be performed and billed to
Medicare. The routine and repetitive monitoring of such patients beyond the first
cardiac stress test, in the absence of a documented change in condition (i.e. new
symptoms or progression of existing symptoms) is not considered medically necessary.
Exercise testing should be supervised by an appropriately trained physician. Exercise
testing in selected patients can be performed safely by properly trained nurses, exercise
physiologists, physician assistants, physical therapists, or medical technicians working
directly under the supervision of a physician, who should be in the immediate vicinity
and available for emergencies.
Given the limitations of uptake, low photon energy and distribution, the perfusion
imaging codes are not generally covered on the same date of service.
Patients with initial abnormal test results have variable pre-test probabilities for
adverse events, and the need and timing of follow up nuclear imaging studies must be
justified in the medical record.
All cardiovascular nuclear tests must be referred by a physician or a qualified non-
physician.
All cardiovascular nuclear tests must be performed under the general supervision of a
physician. The Medicare Carriers Manual describes general supervision as applicable
when a procedure is furnished under the physician’s overall direction and control, but
the physician’s presence is not required during the performance of the procedure. Under
general supervision guidelines, the training of the nonphysician personnel who actually
perform the exercise procedure and the maintenance of the necessary equipment and
supplies are the continuing responsibility of the supervising physician.
Neither exercise testing nor radiologic imaging is indicated in the initial months after
PCI without specific symptoms (i.e., chest pain, ECG changes etc.).
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Cardiovascular stress testing (with or without imaging) and cardiac imaging studies are
not indicated if the results will not affect patient management decisions. If a decision to
perform cardiac catheterization or other angiography has already been made, there is
often no need for cardiovascular stress testing and/or cardiac imaging testing.
In the case of myocardial viability, the FDG positron emission tomography (PET) may
be used following a SPECT that was found to be inconclusive. However, SPECT may not
be used following an inconclusive FDG PET performed to evaluate myocardial viability
CPT/HCPCS Codes
Group 2 Paragraph: N/A
STRESS ECHOCARDIOGRAPHY:
93350
ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH
IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING,
WHEN PERFORMED, DURING REST AND CARDIOVASCULAR
STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR
PHARMACOLOGICALLY INDUCED STRESS, WITH
INTERPRETATION AND REPORT;
93351
ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH
IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING,
WHEN PERFORMED, DURING REST AND CARDIOVASCULAR
STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR
PHARMACOLOGICALLY INDUCED STRESS, WITH
INTERPRETATION AND REPORT; INCLUDING PERFORMANCE OF
CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, WITH
SUPERVISION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH
CARE PROFESSIONAL
93352
USE OF ECHOCARDIOGRAPHIC CONTRAST AGENT DURING
STRESS ECHOCARDIOGRAPHY (LIST SEPARATELY IN ADDITION
TO CODE FOR PRIMARY PROCEDURE)
Group 3 Paragraph: N/A
Group 3 Codes:
MYOCARDIAL PERFUSION IMAGING
78451
MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT)
(INCLUDING ATTENUATION CORRECTION, QUALITATIVE OR
QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST
PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION,
WHEN PERFORMED); SINGLE STUDY, AT REST OR STRESS
(EXERCISE OR PHARMACOLOGIC)
78452
MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT)
(INCLUDING ATTENUATION CORRECTION, QUALITATIVE OR
QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST
Group 2 Codes:
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PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION,
WHEN PERFORMED); MULTIPLE STUDIES, AT REST AND/OR
STRESS (EXERCISE OR PHARMACOLOGIC) AND/OR
REDISTRIBUTION AND/OR REST REINJECTION
78453
MYOCARDIAL PERFUSION IMAGING, PLANAR (INCLUDING
QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION
FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL
QUANTIFICATION, WHEN PERFORMED); SINGLE STUDY, AT
REST OR STRESS (EXERCISE OR PHARMACOLOGIC)
78454
MYOCARDIAL PERFUSION IMAGING, PLANAR (INCLUDING
QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION
FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL
QUANTIFICATION, WHEN PERFORMED); MULTIPLE STUDIES, AT
REST AND/OR STRESS (EXERCISE OR PHARMACOLOGIC) AND/OR
REDISTRIBUTION AND/OR REST REINJECTION
Group 4 Paragraph: The following ICD-9 codes are applicable to Procedure codes 78459,
78491, and 78492 only:
Group 4 Codes:
HEART (CARDIAC) PET
78459 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY
(PET), METABOLIC EVALUATION
78491 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY
(PET), PERFUSION; SINGLE STUDY AT REST OR STRESS
78492 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY
(PET), PERFUSION; MULTIPLE STUDIES AT REST AND/OR STRESS
A9526 NITROGEN N-13 AMMONIA, DIAGNOSTIC, PER STUDY DOSE, UP
TO 40 MILLICURIES
A9552 FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY
DOSE, UP TO 45 MILLICURIES
A9555 RUBIDIUM RB-82, DIAGNOSTIC, PER STUDY DOSE, UP TO 60
MILLICURIES
Please refer to the CMS website for the ICD-10 Codes that Support Medical Necessity .
Documentation Requirements
Medical record documentation maintained by the ordering/referring physician must
indicate the medical necessity for performing the study, including:
• history and physical
• office/progress note, and
• test results
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If the provider of the service is other than the ordering/referring physician, the provider of
the service must maintain hard copy documentation of test results and interpretation,
along with copies of the ordering/referring physician’s order for the studies. The physician
must state the clinical indication/medical necessity for the study in the order for the test.
All segments of the service must have a formal interpretation and report.
When billing for the purchase of radiopharmaceutical(s), the dosage administered, unit
price per dose, name and total charge of the radioactive drug must be on file.
The rationale for selecting pharmacologic stress rather than exercise stress must be
indicated in the medical record.
The medical record must document when significant resting ECG abnormalities are present
or a medication is being used and cannot be withdrawn that would interfere with the
interpretation of a stress ECG, resulting in the selection of a myocardial perfusion study.
Documentation that the required conditions (as indicated in the “Indications and
Limitations of Coverage and/or Medical Necessity” section of this policy) for the PET scan
performed has been met must be maintained by the referring physician in the beneficiary’s
medical record. PET scan facilities must keep patient record information on file for each
Medicare patient for whom such a PET scan claim is made. The medical record must
include standard information (e.g., age, sex, and height) along with any annotations
regarding body size or type that indicates the need for a PET scan to determine the
patient’s condition. Documentation for PET scans for myocardial perfusion imaging or for
myocardial viability that were performed following a SPECT should address the
inconclusive nature of the SPECT by describing if the results were equivocal, technically
uninterpretable, or discordant with the patient's other clinical data in the beneficiary's file.
Documentation for the PET scan for the evaluation of coronary artery disease for
myocardial perfusion that is performed in place of, but not in addition to, a SPECT must
support that the beneficiary had a condition(s) that may cause attenuation problems with
SPECT [e.g., obesity (BMI greater than or equal to 35), large breasts, breast implants, left
mastectomy, chest wall deformity, pleural or pericardial effusion)]. Documentation
containing medical necessity of procedures in addition to testing results such as images and
reports must be maintained. Medical necessity for each service reported must be clearly
demonstrated in the patient’s medical record. When billing for the purchase of
radiopharmaceutical(s), the dosage administered, unit price per dose, name and total
charge of the radioactive drug must be documented in the file.
Utilization Guidelines
It is expected that these services would be performed as indicated by current medical
literature and/or standards of practice. When services are performed in excess of
established parameters they may be subject to review for medical necessity.
Reimbursement of cardiovascular stress testing (93015-93018) which exceeds the frequency
or duration indicated by the accepted standards of medical practice are not covered unless
there are special circumstances which justify additional cardiovascular stress testing. The
routine and repetitive monitoring of such patients beyond the first cardiac stress test, in
the absence of a documented change in condition (i.e. new symptoms or progression of
14— MPI_Heart PET_Stress Echo – CMS - FL
existing symptoms) is not considered medically necessary.
Frequency is considered excessive when services are performed more often than generally
accepted by peers, and the reason for additional services is not justified in the
documentation. Each patient’s condition and response to treatment must medically warrant
the number of services reported for payment. There must be medical necessity for each
service reported to be clearly demonstrated in the patient’s medical record. Repetitive
frequent PET for myocardial perfusion imaging or myocardial viability at a frequency
greater than one per year is not reasonable and necessary in the absence of a documented
change in condition (i.e., new symptoms or progression of existing symptoms). It is expected
that patients will not routinely require the maximum allowable number of services.